Organization
THE SHIELD OF DAVID, INC.
Active
Other names
The Shield Institute
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SUSAN PROVENZANO (EXECUTIVE DIRECTOR)
(718) 886-1682
Entity
Organization
Contact information
Practice address
3909 214TH PL, BAYSIDE, NY 11361-2123
(718) 269-2004
Mailing address
144-61 ROOSEVELT AVENUE, FLUSHING, NY 11354
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
6593164
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00243949
—
NY
Enumeration date
05/31/2006
Last updated
04/24/2018
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